A Quicker Return to Normal: How Hospitals Leverage Enhanced Recovery After Surgery to Improve Care Quality

Annually, more than 234 million major operations are performed worldwide. Of these operations, an estimated 20 percent of patients will suffer post-surgical complications that are known to increase hospital length of stay (HLOS), cost of care and the likelihood of adverse outcomes.

Several evidence-based perioperative care elements exist that hold the potential to reduce post-surgical complications and cost of care while getting patients recovered and home faster. Collectively, these elements form the basis of published enhanced recovery after surgery (ERAS) guidelines now implemented in 20 countries across the globe.

“Why Should My Facility Consider ERAS?”

The short answer: improved surgical outcomes.

ERAS outcome effectiveness is usually demonstrated by improved patient satisfaction with decreases in post-surgical complications, HLOS and cost of care. HLOS is closely associated with the return of bowel function, which is affected by fluid status, gut ischemia, narcotic administration, pain and the presence or lack of early postoperative ambulation and alimentation.

Regional blocks are useful for decreasing opioid exposure. By providing prolonged post-surgical analgesia, they enhance both patient experience and early ambulation.

Proper perioperative fluid management mitigates post-surgical organ dysfunction and associated complications. While both stressed and unstressed circulatory volumes play a role in normal homeostasis, targeted blood pressure management is certainly as important as “getting the fluid right” for mitigating post-surgical complications.

The key elements of ERAS protocol go beyond throughput metrics, opioid use reduction and perioperative fluid management.

“Must ERAS Protocol Adhere to This Established List?”

No. While it’s generally believed that adherence to all guidelines yields the best outcomes, enhanced recovery pathways with as few as two elements have shown value and clinical benefit.

In fact, when Envision’s anesthesiology group implements ERAS protocol with one of our partner facilities, we start with seven core components.

Core Components of Envision ERAS Programs

1. Medical pre-optimization
2. Targeted perioperative fluid management
3. Multimodal pain management
4. Regional anesthetics
5. PONV prophylaxis
6. Narcotic limitation
7. Early ambulation and alimentation

Knowing the core components of ERAS is just half the battle; knowing how to implement these components and secure buy-in for them is the other.

“How do I Implement ERAS Protocol?”

Because ERAS guidelines are so dynamic and multifaceted, introduction of this protocol should be staged in tiers so as not to overwhelm any one group of clinicians or their support teams. With each of the seven core components, clinicians and healthcare leaders will face unique obstacles, but they each share one particular hurdle: building consensus and securing buy-in across leadership and clinical teams.

Securing Buy-in Takes Reinforcement and Perseverance

With every step of implementation, one may encounter doubt, reticence and even apathy regarding the potential benefits of changing perioperative and postoperative protocols. The key to overcoming these challenging attitudes is to continuously demonstrate value to patients, clinicians and hospitals.

When Envision began implementing ERAS protocol nearly a decade ago, we partnered with colorectal surgeons to develop a custom protocol because they have ample experience with multimodal pain.

From discussions with these surgeons, the team gleaned just how effective multimodal pain packages could be at reducing complications and expediting discharge, aiding in the development of new guidelines for the anesthesia and surgical teams. The team condensed this knowledge into toolkit booklets that could be disseminated among Envision partner facilities. Envision also enlisted the help of international experts to coach and, essentially, pitch frontline clinicians on the value of these changes.

However, the best way to demonstrate the value of ERAS protocol is through continuous data collection and follow-up with clinicians, support teams and hospital leaders.

Though this list is not exhaustive, cumulative data summaries can include the following:

• Length of stay by case type vs. pre-ERAS historical average for the facility
• Cost savings due to the ERAS
• ERAS narcotic dosage vs. pre-ERAS historical average for the facility
• Complication rate by case type vs. pre-ERAS historical average for the facility

Delivery of high-quality healthcare relies not only on clinical evidence and expertise but also on the establishment of clear benefits to every party involved — patients, clinicians, hospital leaders and ancillary support staff.

By implementing ERAS protocol even on a smaller scale, we create better perioperative and postoperative conditions for patients and clinicians alike, ultimately improving care quality and patient experience while reducing bed utilization. Prioritizing this protocol will raise the bar on the level of care we can offer our communities, making healthcare work better for everyone.